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1. A. FUll NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MIDRPriel.CeI~fRENT SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
M~rill n (l~
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. s~s~(Mr~~~~~e~~SE) Celaya
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA.~)Vadc' B. ~
C. CHECK ONE 0 CITY 0 TOWN 0 ~LLAGE
~~CIFY ""-ppinlJP-"& !:sd'"
D. STREET ADDRESS 1 Reservoir Piece ~ $ ZIP 1~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? o~S 0 NO
13. A. AGE 23 13.B. DATE OF BIRTH MJ1l / ~ /1RIO
14. EMPLOYMENT
A. USUAL OCCUPATION Food Prep
B. TYPE OF INDUSTRY OR BUSINESS Olltblck ste8kbollse
15. PLACE OF BIRTH (~~en. Mexico
16. FATHER
A. NAME ~nv'"O OjP-rill AIIrriHv
B. COUNTRY OF BIRTH Mexico
17. MOTHER
A. MAIDEN NAME Joe.,. Mill. V....ra
B. COUNTRY OF BIRTH Mexico
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
2. RESIDENCE A. 'tI'lI Vade B. ~BIII
C. CHECK ONE 0 CITY 0 TOWN ~ILLAGE
AND
SPECIFY Wappingea !:.Ikr.
D. STREET ADDRESS 1 Reservoir Plece!VA 9
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 24 3B. DATE OF BIRTH
4. EMPLOYMENT
ZIP 12590
O.fES 0 NO
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESS Outblck stellcholse
5. PLACE OF BIRTH (~~~~90
6. FATHER
A. NAME Rsaltll7l1r eetaye
B. COUNTRY OF BIRTH Mexico
7. MOTHER
A. MAIDEN NAME Plltorl MtACIII
B. COUNTRY OF BIRTH Mexico
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
o
o
(2) 0 DEATH
o
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? MONTH / DAY / YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
OATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (cm:: STATE/COUNTRY, IF NOT USA) SELF SPOUSE
w
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w
(,)
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o 0
o 0
o 0
o D
provl ed Is true and t at declare that no lega impediment exists
22. SIGNATURE OF BRIDE ~ ~
~AME
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATUREOFTOWNORCITYCLERK~ DATE n7~
This license authorizes the marriage in e of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY,
o If checked, this license is to be used ani for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
1ST
2ND
3RD
4TH
I, being duly sworn, depose an
as to my right to enter into th
21. SIGNATURE OF GROOM ~
~
{ SEAL }
'-v-I
NAME (PRINT)
MONTH
DAY
YEAR
MONTH
YEAR
TIME
11-4<tM
- ~M
07
30
09 'Zl 2003
IP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NANED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
27. TYPE OF CEREMONY
o ~ RELIGIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYlJlqI19~
,
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
NAME (PRINT)
SIGNATURE ~